CDI and Coding: The Hidden Components of Healthcare Ratings

It is common knowledge that Clinical Documentation Improvement and HIM coding are integral to healthcare revenue integrity and accurate classification of the severity of illness of a given patient population. 

Many providers, however, fail to realize the powerful impact of CDI and HIM on ratings methodologies such as Hospital Compare (CMS), Healthgrades and US News & World Report Best Hospital Rankings. Consumerism in healthcare has become the norm as patients have developed into sophisticated comparison shoppers who rely upon a plethora of publically available ratings to make informed decisions about where to seek care and how to best spend their healthcare dollars.

Marketplace competition provides hospitals with greater incentive to improve quality, which can lead to fewer complications, lower readmission rates, reduced length of stay, and lower mortality rates.  When considering healthcare ratings, it is critical to first examine the accuracy of an organization’s clinical documentation and coded data that significantly contribute to the rankings themselves. Simply put, poor clinical documentation and incorrect coding directly influence incorrect healthcare ratings. 

Healthcare ratings provide organizations with a unique opportunity to do a focused deep-dive into the integrity of their institutional data. This analytical process, which involves stakeholders from CDI and HIM, should provide an objective assessment of institutional data quality. The findings can be used to correct current documentation and coding deficiencies, identify opportunities for improvement in CDI and coding departments, and proactively monitor data quality over time. 

Documentation and coding are two key methods by which the quality of patient care is judged. Better quality of documentation and coding may directly translate to improved healthcare ratings. MedPartners has identified the powerful impact of a different perspective on HIM audits – ones which are tailored to the specific documentation and coding elements which affect healthcare ratings. Despite the fact that healthcare ratings are an imperfect science, they matter greatly to providers. Consumer perception is their reality and if a healthcare organization’s rankings are unfavorable, consumers may take their business elsewhere—despite the fact that the rankings may not reflect the true level of quality provided by the organization. This is why an organization’s documentation and coding quality must align with their overall quality mission.

For example, Patient Safety Indicators (PSIs) play a major contributory role in Medicare’s Hospital Compare star rating levels that are assigned to hospitals across the nation. The Hospital Compare rating system is divided into 7 categories including Safety of Care. Clinical documentation and HIM coding are most impactful in this category which includes healthcare associated infections, knee and hip replacement complication rates, and serious complications which are drawn from PSIs. 

The overall score for serious complications is based on how often adult patients had certain serious, but potentially preventable, complications related to medical or surgical inpatient hospital care. This composite (or summary) measure – Patient Safety and Adverse Events Composite – is based on the following Patient Safety Indicators: 

• (PSI 3) Pressure sores (pressure ulcers)
• (PSI 6) Collapsed lung that results from medical treatment (Iatrogenic pneumothorax)
• (PSI 8) Broken hip from a fall after surgery (in-hospital fall with hip fracture)
• (PSI 9) Bleeding or bruising during surgery (perioperative hemorrhage or hematoma)
• (PSI 10) Kidney and diabetic complications after surgery (postoperative acute kidney injury requiring dialysis)
• (PSI 11) Respiratory failure after surgery (postoperative respiratory failure)
• (PSI 12) Blood clots, in the lung or a large vein, after surgery (perioperative pulmonary embolism or deep vein thrombosis)
• (PSI 13) Blood stream infection after surgery (postoperative sepsis)
• (PSI 14) A wound that splits open after surgery (postoperative wound dehiscence)
• (PSI 15) Accidental cuts and tears (unrecognized abdominopelvic accidental puncture or laceration)

It is of paramount importance that conditions classified as PSIs are clearly documented and correctly coded. This, however, is not as simple as it may seem. Unclear or ambiguous documentation of PSIs is common, which leads to incorrect coding and false-positive reporting of PSIs that do not truly exist. This scenario will result in incorrect Hospital Compare star ratings. 

Clients leverage MedPartners’ expertise in clinical documentation and HIM coding to help ensure that facilities are reporting clean data which translates into not only correct reimbursement, but an accurate portrayal of the quality of care provided by their facilities. This has a direct impact on the public’s perception. The investment in MedPartners' solutions ultimately reduces lost reimbursement for clients, improves inefficiencies and helps prevent lower quality ratings.

Reference:  https://www.medicare.gov/hospitalcompare/About/What-Is-HOS.html